Bayshore Nursing & Rehab

Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 5 (R6, R33, R40, R65 and R75) of 5 residents reviewed for immunizations and employee records contained documentation related to COVID-19 immunizations for 1 of 1 staff reviewed.*R6's medical record does not contain any documentation as to whether R6 was offered, received, or declined the COVID-19 immunization.*R33's medical record does not contain any documentation as to whether R33 was offered, received, or declined the COVID-19 immunization.*R40's medical record does not contain any documentation as to whether R40 was offered, received, or declined the COVID-19 immunization.*R65's medical record does not contain any documentation as to whether R65 was offered, received, or declined the COVID-19 immunization.*R75's medical record does not contain any documentation as to whether R75 was offered, received, or declined the COVID-19 immunization.*Staff member (CNA-JJ) reviewed had no documentation of COVID-19 vaccination being offered, received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not maintain an effective pest control program to address the flying bugs in the facility. *Surveyors observed active pest activity from flies/flying bugs in multiple areas of the Facility's B Unit. *Surveyors observed active pest activity from flies/flying bugs in multiple areas of the Facility's C Unit. Findings include: On 9/15/25 at 10:10 AM Surveyor observed R10's wound treatment. Surveyor noted several swarms of fruit flies hovering by R10's room door on Facility's C Wing. On 9/15/25 at 10:26 AM, Surveyor observed R4's wound treatment. Surveyor noted several swarms of fruit flies hovering by R4's room door and throughout R4's room on Facility's C Wing. On 9/15/25, at 9:52 AM, Surveyor interviewed Maintenance Director-GG regarding pest control for the facility. Maintenance Director-GG states the facility uses [Pest control company] to put bait stations outside the facility or to put a gel down on the floor if there is a concern with ants.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure that 7 of 8 sampled staff received training on the facility's compliance and ethics program.This has the potential to affect the 85 residents who reside at the facility and have the potential to receive direct and indirect care from these staff. Findings Include:On 9/30/25, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, evidence that the following staff members received training regarding compliance and ethics:Certified Nursing Assistant (CNA)-WW hire date 8/8/23CNA-TT hire date 9/19/23CNA-XX hire date 9/12/22CNA-YY hire date 10/3/23CNA-ZZ hire date 1/5/06Housekeeping-AAA hire date 1/25/24Speech Language Pathologist (SLP)-BBB hire date 5/16/23Registered Nurse (RN)-CCC hire date 2/1/23Surveyor reviewed completed trainings and noted there was not documentation that CNA-WW, CNA-TT, CNA-XX, CNA-YY, CNA-ZZ, SLP-BBB, or RN-CCC received training of the facility's compliance and ethics program on an annual basis.On 9/30/25, at 11:20 AM, Surveyor shared concerns with NHA-A that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility did not ensure 7 out of 8 staff chosen at random received behavioral health training to care for residents diagnosed with a mental, psychosocial, or other behavioral health conditions. This deficient practice has the potential for staff to lack current knowledge to work with the unique challenges mental health illnesses present and has the potential to affect all 85 residents that have the potential to experience behavioral health issues in the facility.Findings include:Surveyor notes, when asking Nursing Home Administrator (NHA)-A for a policy on required annual in-service training, NHA-A stated, the facility does not have a policy on in-service training. On 9/30/25 at 8:40 AM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, evidence that the following staff members received training regarding behavioral health:Certified Nursing Assistant (CNA)-WW, date of hire 8/8/23CNA-TT, date of hire date 9/19/23CNA-XX, date of hire 9/12/22CNA-YY, date of hire 10/3/23CNA-ZZ, date of hire…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents whose Medicare part A benefits ended were provided with written beneficiary protection notifications for 4 (R15, R100, R101, R102) of 5 residents sampled for beneficiary notifications. The facility did not provide 4 Residents (R15, R100, R101, & R102) of 5 sampled residents a written Advanced Beneficiary Notice (ABN), which includes financial liability information and appeal rights, at the time Medicare Part A coverage ended. Findings include: The facility policy titled, Advance Beneficiary Notice Policy implemented [DATE], documents, in part: Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines.:c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered services(s) are ending, no matter if resident is leaving the facility or remaining in the facility. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the Facility did not address and resolve grievances conveyed during Resident Council meetings on behalf of 12 of 12 residents who attended the meeting.Per July Resident Council meeting minutes residents expressed concern that staff were not wearing name tags. Surveyor noted no documentation this was thoroughly investigated, along with an appropriate resolution.Findings include:The Facility Policy titled Resident Council last revised April 2017 documents, in part: Policy Interpretation and Implementation.5. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern.The Facility Policy titled Grievances/Complaints, Filing last revised April 2017 documents, in part: Policy Interpretation and Implementation.3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility did not ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status at the time of the assessment for 12 (R5, R50, R66, R75, R34, R3, R4, R60, R2, R6, R65, and R9) of 20 residents reviewed. * R3, R4, R5, R34, R50, R60, R65, R66, and R75's MDS were inaccurately coded indicating a Preadmission Screening and Resident Review (PASARR) 2 was not required when the resident's PASARR 1 indicated residents having a severe mental illness. * R2's MDS assessment coded R2 having an indwelling foley catheter. R2 does not have an indwelling foley catheter. * R6's MDS did not accurately reflect that R6 had dental issues. * R9's MDS assessment coded anticoagulant use. R9 was not taking an anticoagulant medication. Findings include: 1.) R5 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, mild cognitive impairment, and post traumatic stress disorder. R5 did not have an activated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 4 (R13, R75, R66, R65) of 20 residents reviewed had a comprehensive care plan developed and implemented so that residents can attain their highest practicable physical, mental and psychosocial well-being. *R13, R75, R66, and R65 have diagnoses and or identification of behaviors that the facility has not established individualized care plan's to include interventions for staff to implement based upon assessments of individual residents needs. Findings include: 1.) R13 was admitted on [DATE] with diagnoses of moyamoya disease (a cerebrovascular disorder that affects the brain's blood vessels), sequelae of other cerebrovascular disease, cerebral infarction, unspecified vascular dementia, mild, with agitation. R13's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. Surveyor reviewed R13's care plan and did not observe a care plan that addressed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This deficient practice has the potential to affect all residents residing on the facility's C wing at the time of survey.*Surveyor had observations of residents on facility's C wing not being provided with appropriate activity choices.*Review of the facility's activity calendar indicates that a variety of meaningful activities are not consistently provided at the facility on weekendsFindings Include:Surveyor conducted observation on facility's C wing throughout the survey. On 9/10/25 at 9:00 AM, Surveyor observed R4, R11, R48, R49 and R83 in the C wing dining area around a table. A television in the dining room corner had a morning talk show displayed with muted volume. No activity engagement was observed during this observation.On 9/10/25 at 9:55 AM, Surveyor observed residents on the facility's C wing with 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not complete a performance review at least once every 12 months for 3 of 4 Certified Nursing Assistants (CNA) reviewed. This had the potential to affect all 85 residents who reside in the facility. *The facility was unable to provide a performance review completed within the last year for CNA-JJ.*The facility was unable to provide a performance review completed within the last year for CNA-OO.*The facility was unable to provide a performance review completed within the last year for CNA-PP. Findings include:The facility's Employee Handbook section related to Evaluations documents: All employees will be subject to periodic job performance evaluations by their supervisor. This usually happens at least annually. The evaluation will be reviewed with the employee by the supervisor at the time of presentation.On 09/16/2025, at 8:57 AM, Surveyor interviewed Business Office staff-KK regarding performance reviews for CNA and was told they are done annually on their anniversary date. Surveyor requested to see the last one completed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure the physician acted upon recommendations by the pharmacist for 5 (R3, R6, R33, R58, R66) of 5 residents reviewed with pharmacy recommendations. * R3, R6, R33, R58, and R66 had no documented physician response to pharmacist recommendations after the medication regimen was reviewed during the last six months and no indication pharmacist recommendations were followed up on. Findings include: The facility policy titled Use of Psychotropic Medication(s), with implemented date 1/1/2025 and no revised date, documents: . Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.-A psychotropic drug is any drug that affects brain activities associated with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, to include the opened on or expiration date when applicable for 1 of 2 medication carts reviewed. Medication cart B contained insulin that was not dated when opened and open stock medications that were not dated when opened. Findings include: The Facility policy titled Vials and Ampules of Injectable Medications with effective date of 10/25/2014, documents, in part: Policy: Vials and Ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal.Procedures.B. The date opened and the initials of the first person to use the vial are recorded on multidose vials [on the vial label or an accessory label affixed for that purpose] . F. Medication in multidose vials may be used [until the manufacturer's expiration date/for the length of time allowed by state law/according to facility policy/for thirty days] if inspection reveals no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents Pneumococcal immunizations were offered, or refused, as eligible. This was observed with 4 (R6, R33, R65, and R75) of 5 residents whose immunization records were reviewed. *R6, [AGE] years old, has no documentation of Pneumococcal vaccine being offered *R33, [AGE] years old, has no documentation of Pneumococcal vaccine being offered *R65, [AGE] years old, has no documentation of Pneumococcal vaccine being offered*R75, [AGE] years old, has no documentation of Pneumococcal vaccine being offered Findings include: The facility's policy titled, Infection Prevention and Control Program, implemented 10/1/22 documents, in part: 7. Influenza and Pneumococcal Immunization.:b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere. c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 2 (R33 & R58) of 5 residents and/or their representative that were reviewed, were provided the risks and benefits for prescribed psychotropic medication. 1. R33 received psychotropic medication with no evidence the risks and benefits were explained, reviewed, or provided. 2. R58 received antipsychotic and antianxiety medications with no evidence of risks and benefits were explained, reviewed, or provided. Findings include: The facility's policy titled Use of Psychotropic Medication(s), with implemented date 1/1/2025 and no revised date, documents: .Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.-A psychotropic drug is any drug that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility did not ensure that residents have reasonable access to use the telephone, in a place where calls can be made without being overheard. This concern was expressed by 1 (R35) of 12 residents attending the resident council meeting.Residents with a desire to use a facility phone have the options of the receptionist desk, Social Services office, nurse's station or by the vending and ice machines.Findings include:On 9/10/25, at 1:46pm, during the Resident Council meeting, R35 expressed the concern that if you don't have a cell phone there are no phones in resident rooms. R35 has to go to nurse's station where there is no privacy.On 9/15/25, at 8:32am, Surveyor interviewed Licensed Practical Nurse (LPN) -Y regarding where a resident can use a facility phone and was told they can use the one in the nurses station or by the vending machines off unit B. On 9/15/25, at 8:42am, Surveyor interviewed Director of Social Services (SS)-F and asked about a phone for residents to use and was told when residents have personal calls to make they often use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure a resident's right to a clean, comfortable, and homelike environment for 1 (R32) of 85 resident rooms observed.R32's floor was observed to be very sticky over multiple days. Findings include:The facility policy titled Routine Cleaning and Disinfection with implemented date 1/1/2025 and no revised date documents: . Policy: it is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .-Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products.R32 admitted to the facility on [DATE] with diagnoses including early-onset cerebellar ataxia (unsteady movements due to damage to the part of the brain that controls balance and coordination), depression, anxiety, and hoarding disorder. R32's Quarterly Minimum Data Set (MDS) dated [DATE] documents R32 has a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 (R58) of 5 residents reviewed.R58 did not have adequate monitoring while receiving antipsychotic medication. Findings include:The facility policy titled Use of Psychotropic Medication(s), with implemented date 1/1/2025 and no revised date, documents: . Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.-A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics.-Residents who received an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not report 3 of 3 allegations to the state agency within the required time frame. R58 sustained a fall with fracture that was not reported to the state agency. R66 had an allegation of physical and verbal abuse by a staff member that was not reported to the state agency. R94 had an allegation of verbal abuse by a staff member that was not reported to the state agency within the required 2 hour time frame. Findings include: 1.) R94 was admitted to the facility on [DATE] with Major Depressive Disorder and Alcoholic Cirrhosis (a liver condition exacerbated by chronic alcohol abuse). Surveyor reviewed R94's electronic medical record. Surveyor reviewed a facility self report related to an allegation of verbal abuse between R94 and a staff member that occurred on 7/9/25. Surveyor noted R94's abuse allegation was reported to Director Social Services (SS)-F on 7/10/25. Surveyor noted a facility self report was reported to the state agency on 7/17/25. On 9/11/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 3 of 3 allegations of abuse were thoroughly investigated by the facility. R58 sustained a fall with fracture that was not thoroughly investigated by the facility. R66 had an allegation of physical and verbal abuse by a staff member that was not thoroughly investigated by the facility. R94 had an allegation of verbal abuse by a staff member that was not thoroughly investigated by the facility. Findings include: 1.) R94 was admitted to the facility on [DATE] with Major Depressive Disorder and Alcoholic Cirrhosis (a liver condition exacerbated by chronic alcohol abuse). Surveyor reviewed R94's electronic medical record. Surveyor reviewed a facility self report related to an allegation of verbal abuse between R94 and a staff member that occurred on 7/9/25. Surveyor noted R94's abuse allegation was reported to Director Social Services (SS)-F on 7/10/25. Surveyor noted that the facility's investigation did not include interviews with additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 2 (R2 & R91) of 3 residents reviewed for hospitalizations received the proper notice of transfer or written notice of bed hold policy to include the rate to reserve the resident's bed. *R2 was transferred to the hospital on 5/9/25 and 6/13/25. A bed hold reserve bed payment rate/policy and procedure detail was not provided in writing to R2 upon transfer on 5/9/25, and a transfer notice and bed hold rate was not provided in writing to R2 upon transfer on 6/13/25. *R91 was transferred to the hospital on 7/26/25. A transfer notice and bed hold rate was not provided in writing to R91 upon transfer. Findings include: The facility policy titled Bedhold Notice Upon Transfer with implemented date 3/1/2019 documents: .Policy- at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 (R50) of 11 residents reviewed with a completed level 1 Preadmission Screening and Resident Review (PASARR) indicating a need for the completion of a level 2 PASARR had one completed. *R50's PASARR level 1 indicated R50 is suspected of having a serious mental illness and requires a PASARR level 2 screening. R50 did not have a PASARR level 2 screen completed within 30 days of admission to determine need for specialized services. R50's level 2 PASARR was completed almost 2 years post admission.Findings include:Surveyor notes the facility did not have a PASARR policy and procedure.R50 was admitted to the facility on [DATE] with admitting diagnoses of post-traumatic stress disorder and depression. A diagnosis of generalized anxiety disorder was added on 2/5/24.R50's Physician Orders documents, Buspirone oral tablet 5 mg (milligrams), give 1 tablet by mouth two times a day related to generalized anxiety disorder with an order date of 8/9/24.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure 1 (R2) of 1 resident who is dependent with their activities of daily living received the necessary services to maintain their grooming and hygiene. R2's fingernails were observed to be extremely long, and R2's urinal was observed not to be emptied timely. Findings include:The facility policy titled Providing Nail Care with implemented date 3/1/19 and no revised date, documents: . Policy . the purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health . -identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke .-routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis . -routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R5) of 1 resident reviewed for post traumatic stress disorder (PTSD) received culturally competent, trauma informed care in accordance with professional standards of practice and accounting of resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R5.* R5 does not have a person centered care plan for triggers and interventions for R5's PTSD diagnosis. R5 has no quarterly trauma assessments completed.Findings include:The facility policy titled Trauma Informed Care dated 10/1/2022 documents: It is the policy if this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/ or re-traumatization.Policy Explanation and Compliance Guidelines: .2. The facility will use a multi-pronged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not comprehensively assess a resident before and after applying bed mobility devices. This was observed with 1 (R40) of 1 residents observed with bed mobility devices.*R40 was observed with bilateral bed mobility devices without any attempted alternatives, indication for use, or scheduled maintenance of mobility devices. R40's Bed Rail Assessment was incomplete and documented right bedrail only. R40 does not have a consent signed for mobility devices nor have a mobility device evaluation for installment. R40 does not have a physician order for mobility devices nor a physician order for monitoring of potential residual side effects with a mobility device. Findings include:The facility policy entitled, Use of Restraints Policy, date revised, July 2022, documents in part. Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility did not ensure 1 (R6) of 1 residents reviewed for dental concerns had the necessary services for dental care. On 9/9/25 at 10:23 a.m. Surveyor interviewed R6. R6 explained he had broken teeth and was told he could see the dentist and no one from the facility has helped him with this concern. Surveyor observed broken and missing teeth in R6's mouth. Findings include:R6 was admitted the facility on 12/29/21 with diagnoses of dysphagia, chronic respiratory failure and chronic obstructive pulmonary disease. On 9/9/25 at 10:23 a.m. Surveyor interviewed R6. R6 stated he has missing teeth and needs to see the dentist. R6 showed Surveyor his mouth. R6 had missing and broken teeth. The medical record reveals on 7/23/25 R6 had a dental exam and the dental note documents, patient has 13 teeth/roots present. Patient had several teeth extracted last year and was supposed to have another oral surgery appointment for more extractions. Facility staff needs to set up oral surgery appointment. Will follow up after extractions are done for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon interview and record review, the facility did not ensure the medical records for 1 (R95) of 1 residents was accurate and complete based upon standards of practice.R95 was transferred to a hospital for care. The medical record does not include documentation for the reason for the transfer and where R95 was transferred to.Findings include:R95 was admitted to the facility on [DATE] with diagnoses of morbid obesity, chronic obstructive pulmonary disease and type 2 diabetes. The discharge MDS (minimum data set) dated 7/18/25 documents R95 was discharged to the hospital. The nurses notes does not document any assessment related to the need to send R95 to the hospital. On 9/16/25 at 3:15 p.m. Surveyor interviewed DON-B. Surveyor explained the concern R95 was discharged to the hospital and there isn't documentation of an assessment related to the need to send R95 out to the hospital. DON-B stated she understood and had no information. DON-B stated she expects nurses to document an SBAR (situation, background,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure that 1 of 4 Certified Nursing Assistants (CNA-JJ) reviewed completed the required annual 12 hours of educational training. Findings include: The Facility Assessment Tool last updated 5/2025, documents required in-service training for nurse aides. In-service training must:-Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year.On 9/16/25, at 11:04am, Surveyor interviewed business office-KK regarding the four CNA employed over one year that Surveyor requested annual training hours for. One of the CNA only had 2.1 hours in the last year and was hired on 8/8/23. Business office-KK will look into why CNA-JJ is short.On 9/16/25, at 1:20pm, Surveyor interviewed business office-KK again and was told when the report was run again it shows 5.6 hours of training which is still short of the 12 required. Surveyor asked how the facility monitors that training is being completed. Business office-KK responded that they do monthly audits. Surveyor asked how CNA-JJ fell through the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility did not ensure 1 (R1) of 3 Residents were provided with reasonable accommodations of Resident needs and preferences. R1 does not eat the Facility food and has her meals delivered one time a week. R1 stores her food in her room refrigerator and requests to have her food heated. The Facility was aware R1 does not eat the Facility food and did not heat R1's meal when requested.Findings include:The Facility policy entitled, Resident Rights, dated 3/1/25, documents, in part, .Policy Explanation and Compliance Guidelines: .All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents.Resident Rights. The resident has the right to a dignified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents right to be free from abuse for 1 of 1 (R5) residents reviewed for abuse.Facility staff witnessed a CNA (Certified Nursing Assistant) verbally abuse R5. The verbal abuse was not immediately reported to the Nursing Home Administrator, and the CNA continued to work the remainder of their shift, putting R5 and other residents at risk for additional abuse.Findings include:The facility's policy titled Abuse/Neglect/Exploitation which was not dated, documents:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation and misappropriation of resident property.V. Investigation of alleged abuse, neglect and exploitation.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur.VI. Protection of a ResidentD.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that allegations of verbal abuse and/or misappropriation were immediately reported to the Nursing Home Administrator for 2 of 3 (R2 and R5) residents reviewed for abuse.R2's allegation of misappropriation of money and property was not reported to the Nursing Home Administrator (NHA)-A-or Social worker, resulting in delay of reporting to the State Agency.R5's (witnessed) verbal abuse was not immediately reported to the NHA-A or Social worker.Findings include:The facility's policy titled Abuse/Neglect/Exploitation which was not dated, documents:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation and misappropriation of resident property.V. Investigation of alleged abuse, neglect and exploitation.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. The facility Dietary Director (DD)-T does not have a qualified certificate to manage the kitchen and is working under the supervision of Registered Dietitian (RD)-Q. RD-Q is working remotely from home and at other facilities and is not on-site full time for supervision. This had the ability to affect 91 of 91 residents.Findings include:On 7/3/25, at 8:05 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who states DD-T is not certified as a food service manager or dietary manager. NHA-A states he sent in a request for a waiver to the State Agency due to DD-T not being certified. NHA-A states DD-T is trying to enroll in school again to become a certified dietary manager . NHA-A states DD-T's school is online through another state and has been attempting to contact the school by email to re-enroll in classes. Surveyor requested a copy of the contract between the facility and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not implement and maintain an effective training program for facility staff consistent with their expected roles and based on the facility assessment for 5 of 5 facility staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P). This has the potential to affect the total census of 91 residents. Findings include: The facility's assessment titled, Facility Assessment Tool last updated in April, 2025 and reviewed by the Quality Assurance Committee on May, 2025 documents under the Titled section: Staffing 3.4 staff training/ education and competencies documents that [facility name] provides staff training/ education and competencies that is necessary to provide care and support needed for our resident population. The training/ education and competencies/skill checks are generally provided upon hire, during monthly in-servicing/ training, annual in-servicing/training, whenever an area of concern is identified, or new areas are identified based on resident diagnoses and/or clinical condition. [Facility name] provides the training on topics and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received mandatory training in effective communication. This has the potential to affect the total census of 91 residents. Findings include: On 7/2/25, Surveyor requested from DON ( Director of Nursing)- B, evidence that the following direct care staff received training in effective communication.CNA- L hire date 8/8/23CNA-M hire date 7/25/23CNA-N hire date 6/13/23CNA-O hire date 8/8/23CNA-P hire date 12/15/21On 7/2/25 at 1:03 PM, DON- B was not able to provide Surveyor with any evidence that CNA-L, CNA-M, CNA-N, CNA-O, and CNA-P had received the mandatory training in effective communication. On 7/2/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator- A who also confirmed that the facility does not have evidence that the 5 Certified Nursing Assistants mentioned above completed the required training for effective communication. No additional information was provided.

Based on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received training on resident rights and facility responsibilities to properly care for its residents. This has the potential to affect the total census of 91 residents. Findings include: On 7/2/25, Surveyor requested from DON ( Director of Nursing)- B, evidence that the following staff members received training in resident rights.CNA- L hire date 8/8/23CNA-M hire date 7/25/23CNA-N hire date 6/13/23CNA-O hire date 8/8/23CNA-P hire date 12/15/21On 7/2/25 at 1:03 PM, DON- B was not able to provide Surveyor with any evidence that CNA-L, CNA-M, CNA-N, CNA-O, and CNA-P had received training regarding resident rights and facility responsibilities. On 7/2/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A who also confirmed that the facility does not have evidence that the 5 Certified Nursing Assistants mentioned above completed the required training for resident rights and facility responsibilities.

Based on interview and record review, the facility did not ensure that 5 of 5 staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received training regarding abuse, neglect and exploitation and what activities constitute abuse, procedures for reporting and dementia management and resident abuse prevention. This has the potential to affect the total census of 91 residents. Findings include: On 7/2/25, Surveyor requested from DON ( Director of Nursing)- B, evidence that the following staff members received training regarding abuse prevention:CNA- L hire date 8/8/23CNA-M hire date 7/25/23CNA-N hire date 6/13/23CNA-O hire date 8/8/23CNA-P hire date 12/15/21On 7/2/25 at 1:03 PM, DON- B was not able to provide Surveyor with any evidence that CNA-L, CNA-M, CNA-N, CNA-O, and CNA-P had received training regarding abuse prevention, reporting and dementia management. On 7/2/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A who also confirmed that the facility does not have evidence that the 5 Certified Nursing Assistants mentioned above completed the required training abuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P). received training regarding elements and goals of the facility's QAPI (quality assurance and performance improvement program). This has the potential to affect the total census of 91 residents. Findings include: On 7/2/25, Surveyor requested from DON ( Director of Nursing)- B, evidence that the following staff members received training regarding the QAPI program:.CNA- L hire date 8/8/23CNA-M hire date 7/25/23CNA-N hire date 6/13/23CNA-O hire date 8/8/23CNA-P hire date 12/15/21On 7/2/25 at 1:03 PM, DON- B was not able to provide Surveyor with any evidence that CNA-L, CNA-M, CNA-N, CNA-O, and CNA-P had received training regarding the facility's QAPI program.On 7/2/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A who also confirmed that the facility does not have evidence that the 5 Certified Nursing Assistants mentioned above completed training regarding the facility's QAPI program. No additional information was provided.

Based on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received mandatory training on infection control standards, policies and program. This has the potential to affect the total census of 91 residents . Findings include: On 7/2/25, Surveyor requested from DON ( Director of Nursing)- B, evidence that the following staff members received infection control training :CNA- L hire date 8/8/23CNA-M hire date 7/25/23CNA-N hire date 6/13/23CNA-O hire date 8/8/23CNA-P hire date 12/15/21On 7/2/25 at 1:03 PM, DON- B was not able to provide Surveyor with any evidence that CNA-L, CNA-M, CNA-N, CNA-O, and CNA-P had received infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program.On 7/2/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A who also confirmed that the facility does not have evidence that the 5 Certified Nursing Assistants mentioned above completed the required training regarding infection control and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility did not ensure that 5 of 5 direct care staff (CNA- L , CNA-M CNA-N, CNA-O, CNA-P) received training on compliance and ethics. This has the potential to affect the total census of 91 residents . Findings include: On 7/2/25, Surveyor requested from DON ( Director of Nursing)- B, evidence that the following staff members received training regarding compliance and ethics:CNA- L hire date 8/8/23CNA-M hire date 7/25/23CNA-N hire date 6/13/23CNA-O hire date 8/8/23CNA-P hire date 12/15/21On 7/2/25 at 1:03 PM, DON- B was not able to provide Surveyor with any evidence that CNA-L, CNA-M, CNA-N, CNA-O, and CNA-P had received training regarding compliance and ethics on an annual basis. On 7/2/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A who also confirmed that the facility does not have evidence that the 5 Certified Nursing Assistants mentioned above completed the required training regarding compliance and ethics.No additional information was provided.

Based on interview and record review, the facility did not ensure that 5 of 5 Certified Nursing Assistants (CNA- L , CNA-M CNA-N, CNA-O, CNA-P). received the required 12 hours of training per year. This has the potential to affect the total census of 91 residents . Findings include: On 7/2/25, Surveyor requested from DON ( Director of Nursing)- B, evidence that the following staff members had completed the required 12 hours of annual training:CNA- L hire date 8/8/23CNA-M hire date 7/25/23CNA-N hire date 6/13/23CNA-O hire date 8/8/23CNA-P hire date 12/15/21On 7/2/25 at 1:03 PM, DON- B was not able to provide Surveyor with any evidence that CNA-L, CNA-M, CNA-N, CNA-O, and CNA-P had received the required 12 hours of annual training as required. On 7/2/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)- A who also confirmed that the facility does not have evidence that the 5 Certified Nursing Assistants mentioned above completed the 12 hours of annual training.No additional information was provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not report 1 of 2 allegations of abuse or neglect to the Nursing Home Administrator (NHA) or State Survey Agency during the required timeframe. * R8 pushed the Urgent Response button on R8's cellphone, which activates 911, when R8 was left on the bedpan for an extended period of time. This allegation of potential neglect was not reported in a timely manner as required to the Nursing Home Administrator (NHA) and the state agency.Findings include:The facility's undated policy titled Abuse/Neglect/Exploitation documents (in part):Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Policy Explanation and Compliance Guidelines .:2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R8) of 2 allegations of abuse or neglect that were 1reviewed.R8 pushed the Urgent Response button on cellphone, which activates 911, when R8 was left on the bedpan for an extended period of time. Documentation of an investigation of the alleged incident were not located or provided.Findings include:The facility's undated Policy titled Abuse/Neglect/Exploitation documents (in part):Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Policy Explanation and Compliance Guidelines:2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 2 (R1 and R4) of 9 residents received necessary care and treatment. * R4 was admitted to the facility on [DATE] with a surgical wound to the toes on the left foot. A comprehensive wound assessment was not completed until 1/30/25. R4 was readmitted on [DATE] and a comprehensive wound assessment was not completed until 2/21/25. * R1 had a physician order for an air mattress to be used. Surveyor observed R1 to not have an air mattress. R1 is at high risk for skin impairment. Findings include:1.) R4 was admitted to the facility on [DATE] with diagnoses of chronic osteomyelitis of left ankle/foot, type 2 diabetes, asthma, dementia and schizophrenia. R4 discharged to the hospital on 5/29/25 due to a change in condition and has not returned to the facility. R4's admission nurses note dated 1/27/25 documents: LLE (lower limb extremity) necrotic toe s/p (status post) 2nd-4th toe amp (amputation) with metatarsal head resection on 1/21/25. There…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 1 (R5) of 2 residents reviewed for pain management received pain management consistent with professional standards of practice and a resident's goals and preferences related to pain management.* The facility did not provide prescribed needed pain medication or offer non-pharmacological interventions for pain management for R1 on 4/16/25. The facility did not implement recommended pain medication and pain management prescribed by R1's pain clinic on 4/16/25. The facility did not update R5's care plan with person centered interventions for pain management.Findings Include:The facility's policy dated 1/1/25 titled Pain Management documents: The facility must ensure that pain management is provided to Resident who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences. 1. In order to help a Resident attain or maintain his/her highest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide pharmaceutical services to ensure medications were available to be administered as ordered by their physician to meet their medical needs for 1 (R1) of 4 residents.* R1 has an order to receive Oxycodone 5mg (milligrams) 3 times a day for pain related to other chronic pain effective 5/3/25. Prior to 5/3/25, R1 was receiving 7.5 mg of Oxycodone. R1 did not receive this pain medication on 4/26/25, 6/7/25 and 6/8/25 despite voicing pain. Findings include:The facility was not able to provide a policy and procedure for medications to be available by pharmacy to be administered per physician orders.R1 was admitted to the facility on [DATE] with diagnoses that include Systematic Lupus(illness when immune system attacks healthy tissues and organs), Essential Hypertension(chronic condition of persistently high blood pressure), Morbid Obesity(too much body fat), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff used appropriate personal protective equipment (PPE) for two (Residents (R)1 and R13) of two observed for enhanced barrier precautions (EBP) out of 15 residents reviewed in the sample. This failure had the potential to expose residents to infection. Findings include: Review of facility policy titled Enhanced Barrier Precautions with an implementation date 02/25/24 revealed, Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. An order for enhanced barrier precautions will be initiated for residents with any of the following: wounds (chronic wounds such as pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) indwelling medical devices, tracheostomies, feeding tubes. Personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to inform a resident of a lab draw so the resident could make a decision regarding the procedure for one (Resident (R) 3) of three residents reviewed for self-determination out of a total sample of 15 residents. This had the potential for the resident not be able to make a decision about daily care and services. Findings include: Review of the facility's undated policy titled, Your Rights and Protections as a Nursing Home Resident, indicated, As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. You have the . right to be informed, make your own decisions, and have your personal information kept private . . Get Proper Medical Care: You have the following rights regarding your medical care: . To participate in decisions that affects your care . Review of R3's admission Record found on the Profile page of the electronic medical record (EMR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of R1's admission Record located in the EMR under the tab titled Profile revealed the resident was admitted to the facility on [DATE] with a diagnosis of gastrostomy (g-tube). Review of R1's Physician Orders dated 03/14/25 located in the resident's EMR under the tab titled Orders revealed the resident was to receive Nepro with Carb Steady at 60 centimeters (cc) from 6:00 PM to 6:00AM for a total of 720 cc. During an observation on 05/27/25 at 9:00AM revealed the resident was in bed positioned on his right side facing the door. The intravenous pole and feeding pump had dried, beige color, formula splatter. During an observation on 05/28/25 at 8:45 AM revealed the resident had tube feeding infusing at 60 ccs an hour with a water bolus bag hanging. The IV pole and feeding pump had dried beige color formula splatter. 3. Review of R9's admission Record located in the resident's EMR under the tab titled Profile revealed the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one (Resident (R) 3) of 15 residents whose assessments were reviewed in a total sample of 15 residents. The facility failed to accurately assess the rejection of care for R3. This failure placed the resident at risk of having unmet care needs and services. Findings include: Review of the facility's undated policy, titled MDS, indicated, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . 4. Care Plan Team Responsibility for Assessment Completion: . a. ii. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections . Review of the admission Record found on the Profile page of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE]. Review of R3's Care Notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to develop a baseline care plan for one Resident (R)1 from a total of 15 residents reviewed for care plans. This failure had the potential to cause staff to not provide the necessary instructions needed to provide effective care and meet the needs of resident. Findings include: Review of the facility document titled Baseline Care Plan with an implementation date of 03/01/19 revealed . the base line care plan will be developed within 48 hours of a resident's admission .include the minimum healthcare information necessary to properly care for a resident .a written summary of the baseline care plan shall be provided to the resident and representation in a language that the resident/representative can understand . Review of R1's admission Record located in the resident's electronic medical record (EMR) under the tab titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included nontraumatic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview, and review of facility policies, the facility failed to revise the care plan of one resident (R2) out of 15 residents reviewed for care plans out of a total sample of 15 residents related to a new medication and a self-administration assessment. This had the potential for staff to not be aware of the resident's ability to administer medication per herself and cause confusion. Findings include: Review of the facility policy titled Comprehensive Care Plans with a review date of 10/01/22 revealed .the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment . Review of the facility policy titled Self-Administration of Medications with an effective date of 10/25/14 revealed .The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one (Resident (R) 4) of three residents reviewed for transportation services to outside medical appointments were transported to the correct medical provider out of a total of 15 sampled residents. This failure created the potential for medical needs to remain unaddressed for the resident. Findings include: Review of R4's Medical Diagnosis, sheet located in the Med [Medical] Diag [Diagnosis] tab of the Electronic Medical Record (EMR), indicated, the resident was admitted to the facility on [DATE] with diagnoses including fractures of the right arm, left arm, tibia, ribs, and humerus following a motor vehicle accident. Review of R4's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/27/25 located in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 05/27/25 at 3:15 PM, R4 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to properly position urinary drainage bag for one resident (R)1 from a sample of three residents with urinary drainage bags out of a total sample of 15 residents reviewed. This failure has the potential to promote reoccurring urinary tract infections (UTIs). Findings include: Review of the facility's undated policy titled Catheter Care revealed It is the policy of this facility to provide catheter care to call residents that have an indwelling catheter in an effort to reduce bladder and kidney infections . Review of R1's admission Record located in the resident electronic medical record (EMR) under the tab titled Profile revealed the resident was admitted to the facility on [DATE] with a diagnosis that included UTIs. Review of R1's admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 01/23/25 located in the resident's EMR under the tab titled MDS revealed the resident had an indwelling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy, the facility failed to provide care of oxygen equipment for two residents (R9 and R15) from a sampled fifteen residents. The oxygen tubing for R9 was unlabeled with a date and sticky to the touch. This failure has the potential to provide unsanitary equipment for oxygen therapy. Findings include: Review of a facility undated policy titled Oxygen Administrationrevealed .Change oxygen tubing and mask/cannula weekly and as needed if becomes soiled or contaminated. Change the humidifier bottle when empty, every 72 hours or as recommended by the manufacturer. If applicable change the nebulizer tubing and delivery devices every 72 hours and as needed if they become soiled or contaminated. 1. Review of R9's admission Record located in the electronic medical record (EMR) under the tab titled Profile revealed the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included acute and chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Uncorrected on revisit Based on observation, interview and record review, the facility did not ensure the Residents environment was comfortable and homelike. During the survey, the heat was not operational in areas of the facility and did not maintain a comfortable, homelike environment/living temperature for Residents within the facility. This had the potential to effect all 92 Residents residing in the facility at the time of the survey. * During the survey, the internal temperatures of the facility common areas and resident rooms were noted to be cold. Residents expressed they were not warm and comfortable in the facility. Residents were observed wearing winter coats, hats, multiple layers of clothing and using blankets to try to stay warm. Residents shared they were trying to seal out drafts in their rooms themselves instead of facility staff addressing the issues. The facility heating system was not maintaining comfortable temperatures for residents as well as multiple windows throughout the facility were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure 2 (R32 & R1) of 3 residents were assessed by the interdisciplinary team to determine it was clinically appropriate to self administer medication. * R32's albuterol inhaler was observed on the over bed table next to R32's bed. * On 1/23/25 two aspirin tablets were observed in a medication cup in R1's room. There was also a bottle of Vitamin C 1000 mg (milligrams), a bottle of Vitamin B12 500 mg, three bottles of Potassium Gluconate, and two bottles of Super B Complex observed in R1's room. Findings include: The facility's policy titled, Self-Administration of Medications with an effective date 10/25/14 under policy documents In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure a residents physician was consulted with for 2 (R32 & R33) of 3 residents reviewed. * R32's physician was not consulted with when R32 received medication late for medication that were to be received BID/TID/QID (two times daily/three times daily/four times daily) on 12/30/24 to 1/22/25. * R33's physician was not consulted with when R33 received medication late for medication to be received BID/TID on 1/2/25 to 1/22/25. Findings include: 1.) R32's diagnoses includes systemic lupus erthematosus, asthma, morbid obesity, chronic pain, depression, hypertension and anxiety disorder. * On 12/30/24 Cyclobenzaprine HCI 10 mg three times a day & Buspirone HCI 15 mg three times a day were scheduled at 8:00 a.m. R32 received these medications at 11:37 a.m. This is three hours after the scheduled medication time. On 12/30/24 Propranolol HCI 10 mg (milligrams) two times a day scheduled at 8:00 a.m. was administered at 13:28 (1:28 p.m.). On 12/30/24 Gabapentin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility did not ensure 1 (R32) of 4 residents reviewed for grievances had their grievances resolved. * R32's grievance regarding missing clothing in September 2024 was not resolved. Findings include: The facility's policy titled, Grievance and not dated under policy documents It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC (long term care) facility stay. The facility will ensure prompt resolution of all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by a designated Grievance who will be responsible for receiving and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not provide pharmaceutical services to meet the needs of each resident for 2 (R32 & R33) of 3 Residents. * R32 did not receive scheduled medications one hour before or one hour after the scheduled time 48 times between 12/29/24 & 1/22/25. R32's medication during the day shift on 12/15/24 was not checked and initialed as being administered. * R33 did not receive scheduled medication one hour before or on hour after the scheduled time 27 times between 1/2/25 & 1/22/25. Findings include: The facility's policy titled, Medication Administration with an effective date 10/24/14 under procedures documents 12) Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. The 11/20/24 Resident Council Minutes under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 3 medication errors in 30 opportunities which resulted in a medication error rate of 10%. Medication errors were identified for R44, R45, & R32. * R44 did not receive the correct dose of Folic Acid. * R45 did not receive multivitamin with minerals. * R32 did not receive the correct dose of Vitamin B12. Findings include: 1.) On 1/22/25, at 8:21 a.m., Surveyor observed LPN (Licensed Practical Nurse)-M prepare R44's medication which consisted of Aspirin 81 mg (milligrams) one tablet, Gabapentin 100 mg one capsule, Vitamin B1 (Thiamine) 100 mg one tablet, Iron 325 mg one tablet, Levetiracetam 500 mg one tablet, Eliquis 5 mg one tablet, Folic Acid 400 mcg (micrograms) one tablet, and Clear Lax 17 grams. At 8:28 a.m. Surveyor verified with LPN-M the number of pills in the medication cup. LPN-M then opened the Gabapentin capsule, crushed R44's medication and mixed the medication with applesauce. LPN-M added water to the Clear Lax. At 8:30 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility policy, the facility failed to provide a sanitary environment for residents in three of four building wings (A, B, and C wings). This failure had the potential to promote the spread of disease and provide a breeding ground for pests. Findings include: A review of the facility's policy titled, Environmental Services Inspection, implemented on 10/01/23, read in part, It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. The Director of Environmental Services will perform random and/or routine inspections using the Environmental Room Attendants Checklist. An initial environmental tour was conducted on 10/18/24 at 1:10 PM, and the following areas of concern were identified: 1. B Wing a. The privacy curtain around Resident (R)13's bed was partially loose from the track. The privacy curtain had a large greyish colored stain. b. The pole…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of facility policy, the facility failed to ensure the facility's garbage was properly stored in two of two dumpsters and one enclosed area and disposed of timely. The failure had the potential to promote a breeding ground for pests and rodents. Findings include: A review of the facility's document titled, Garbage Disposal, with a revision date of 03/26/24, read in part, Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. The surrounding area shall be kept clean so that accumulation of debris and insect rodent attractions are minimized. Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster. The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse. Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, review of facility policy, and a review of the facility's contract, the facility failed to maintain an effective pest control program throughout the facility. This had the potential to affect 102 of 102 residents who resided at the facility. During the survey, gnats and flies were observed in resident rooms, common areas, and in the administrative offices. This had the potential to promote the spread of disease and promote unsanitary conditions. Findings include: A review of the facility's policy titled, Pest Control Policy, with a revision date of 04/14/24, read in part, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. The facility will utilize a variety of methods in controlling certain seasonal pests, i.e., flies. These will involve indoors and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. A review of the facility's Pest Contract, dated 01/11/23 and provided by the facility, revealed that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and policy review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for one of four residents (Resident (R) 4) reviewed for abuse out of a total sample of 14. Certified Nursing Assistant (CNA) spoke to R4 using verbally abusive language and had potentially aggressive behavior. Failure to protect residents from abuse has the potential to result in injury to residents. Findings include: Review of the facility's policy titled, Abuse/Neglect/Exploitation, with no initiation date, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Review of R4's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 11/07/23 with medical diagnoses including major depressive disorder and end stage renal disease. Review of R4's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon interview and record review, the facility's governing body failed to fulfill the responsibilities of the governing body to include establishing an implementing policies and procedures regarding the operations of the facility. This has the potential to affect all 101 residents present in the facility at the time of the survey. The facility's governing body did not ensure contracted vendors were reimbursed and paid in accordance with established contracts or invoiced amounts causing the facility's fiscal accounts to be in arrears. This has created the likelihood where good and services necessary to maintain operations of the facility along with care and treatment of the residents may be impacted by the failures of the governing body. Findings include: The facility Governing Body policy Implemented 3/1/23 documents: The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. Policy Explanation and Compliance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the Facility did not dispose of garbage and refuse properly having the potential to affect all 100 residents in the Facility. Findings include: On 6/19/24 at 1:56 pm Surveyor observed: *15 [NAME] pallets piled up on the ground near the dumpster. *5-gallon bucket full of a chemical substance outside near dumpster and dryer vent The Facility's policy titled: Waste Disposal Policy, with an implementation of 03/01/2020, documents in part: dumpster's shall be emptied according to the facilities contract. Garbage should not accumulate or be left outside the dumpster. The Facility provided Surveyor with the Safety Data Sheet for the chemical product, Pyxis Sour. Surveyor reviewed the document titled: Safety Data Sheet which documents in part: Product name: Pyxis Sour . 7. Handling and Storage P402 Store in dry place. P402 store locked up. On 06/20/2024, at 09:09 AM, Surveyor informed Nursing Home Administrator (NHA)-A of above concerns. NHA-A stated the dumpster will be picked up twice per week. NHA-A stated if needed, they get big…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review, the Facility's water management program (WMP) was inaccurate, incomplete and was not consistent with current American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guidelines, the Centers for Disease Control and Prevention (CDC) Toolkit, and the Wisconsin State Plumbing Code SPS 382.50, creating a potential for all 100 facility residents to be infected by Legionella or other water born bacteria. In addition, the Facility did not store or process linens to prevent the spread of infection. The WMP did not: ~Include water management team members who were knowledgeable about the facility's water system. ~Describe the building water system using an accurate flow diagram of the system with specific locations. ~Identify all locations where Legionella could grow and spread. ~Include a process to confirm the WMP is being implemented and is effective. The facility laundry was observed to have: ~ Dirty linens in cart labeled clean linen only. ~Saturated bath blankets between washers from leaking washing machines.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the Facility did not maintain mechanical and/or electrical equipment in safe operating condition having the potential to affect all 100 residents in the Facility. Surveyor observed the following outside as a potential fire hazard: *Dryer vent with copious amounts of lint. Findings include: The facility's maintenance task log, titled: check dryer, documents in part, lint removed from exhaust ducts Log documents this task was competed once per month by Maintenance Director (MD)-D. On 06/19/2024, at 01:56 PM, Survey observed the outside dryer vent to be completely covered in lint. A few feet from the dryer vent, was a 5-gallon bucket of Pyxis Sour and a few feet from the bucket of Pyxis Sour was 15 wood pallets near the dumpster. On 06/20/2024, at 09:09 AM, Surveyor informed Nursing Home Administrator (NHA)-A of above concerns. On 06/20/2024, at 11:33 AM, Surveyor interviewed MD-D. MD-D stated he cleans the outside dryer vents once per month as indicated in the electronic maintenance task system.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment for 2 of 4 resident units with the potential to affect 53 residents residing on the units. Findings include: On 6/20/24 at 9:30 AM the following were observed on the B unit. * The entrance to the hall, on the east wall, was observed with an approximately 11 inch x 8 inch area not painted same color, with nails in the wall. The handrail was observed to be loose right under this area. * The entrance to the hall, on the west wall, was observed with an approximately 8 inch by 4 inch area of missing drywall and was not painted. * A brown substance was observed on the wall outside of room [ROOM NUMBER] at baseboard. * The baseboard was missing in the hall between rooms [ROOM NUMBERS]. * R29's room was observed and R29 pointed out her sink, which she indicated had been leaking 2-3 days. The sink was observed to have a partially filled basin with water under it and a wet bath blanket. There was also a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not provide reasonably accommodated access to 1 (R16) of 20 sampled residents who did not have equipment repaired timely according to resident's preference. * R16's wall fan was broken and not repaired or replaced timely. Findings include: R16 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Chronic Respiratory Failure. R16's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and documented R16 had a Brief Interview for Mental Status score of 14 which would indicate he is cognitively intact and able to make his needs known. On 06/17/24 at 9:36 AM, Surveyor observed R16 lying in bed in his room. R16 indicated that the fan on his wall was removed about 2 months ago and not repaired or replaced. R16 indicated he was very hot and uncomfortable in his room. R16 indicated he [NAME] stays in his bed in his room. On 6/18/24 at 8:54 AM, Surveyor observed R16 lying in bed in his room. R16 indicated he was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and record review the facility did not ensure advanced directives were in the resident's medical record for 1 (R2) of 20 residents reviewed. R2 did not have a State Do Not Resuscitate (DNR) form to indicate if R2 was a full code or DNR. R2 had a facility DNR/ cardiopulmonary resuscitation (CPR) instruction consent form filled out that indicated R2 was a DNR however, a green sheet was located in R2's hard chart that had FULL CODE printed on it. Findings include: R2 was readmitted to the facility on [DATE] and has diagnoses that include metabolic encephalopathy, end stage renal disease- dependent on renal dialysis Type 2 diabetes mellitus, protein-calorie malnutrition, cerebral infarction with dysphagia and dysarthria, major depressive disorder, schizophrenia, heart failure, anxiety disorder, prostate cancer, and history of alcohol and cocaine abuse. R2's admission minimum data set (MDS) dated [DATE] indicated R2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility did not ensure the 3 of 8 staff reviewed received the necessary background checks every four years. This had the ability to affect all 99 residents. CNA F's last background check was completed on 3/18/20 and the required 4 year check was due 3/18/24 and this was not completed. CNA G's last background check was completed on 3/12/20 and the required 4 year check was due 3/12/24 and this was not completed. CNA H's last background check was completed on 3/111/20 and the required 4 year check was due 3/11/24 and this was not completed. Findings include: The facility's Abuse/Neglect/Exploitation policy (undated) documents: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility did not ensure individualized comprehensive care plans were initiated for 1 (R94) of 5 residents reviewed for unnecessary medications and 1 (R94) of 1 resident's reviewed for the use of an indwelling catheter. R94 was prescribed an antidepressant medication and was admitted with an indwelling catheter. R94 did not have a comprehensive plan of care with individualized interventions to address the use of an antidepressant medication or for R94's indwelling catheter. Findings include: The facility policy entitled COMPREHENSIVE CARE PLAN' dated 10/1/2022 documents: It is the policy for this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframe's to need a resident's medical, nursing, and mental and psychosocial needs that ate identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: . 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (R64) of 5 residents reviewed for falls. R64 had unwitnessed falls on 3/29/2024, 5/6/2024 (4 falls same day), and 5/16/2024. R64 had a habit of moving self to the floor. Fall investigations were not thoroughly investigated to document when R64 was last checked on, toileted, what interventions were in place, or why R64 was lowering self to the floor. Findings include: The facility policy entitled Falls Management Process dated 2011 documents: . 5. If able, ask the resident to explain what happened and what they were attempting to do at the time of the fall (helpful for root cause analysis later). 11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. The nurse will determine the most appropriate intervention, implement, and update care plan. R64 was admitted to the facility on [DATE] and has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; for 1 (R34) of 7 residents reviewed for nutrition. R34 sustained a significant weight loss of 9.60% from 2/7/24 to 5/10/24. R34's weights were not obtained in accordance with R34's physician orders. Findings include: The facility policy titled Weight Monitoring which was not dated, documents (in part) .Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Weight can be a useful indicator of nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility did not ensure 1 of 2 medication storage rooms did not have expired stock medications. On [DATE] Surveyor observed 4 bottles of Vitamin B12 stock medication that was expired on 3/24 and 1 bottle of docusate sodium expired 4/24. Findings include: On [DATE] at 10:34 a.m. Surveyor observed the C and D wing medication storage room along with Director of Nursing (DON)-B. Surveyor discovered 4 bottles of Vitamin B12 stock medication that was expired on 3/24 and 1 bottle of docusate sodium expired 4/24. Surveyor showed the expired stock medications to DON-B. DON-B stated she thought they look all the stock medications for expired meds. DON-B had no further information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not provide adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member, or to a centralized staff work area, for 1 residents (R16) out of 20 sampled residents. * R16's call light did not work when pressed and R16 had to pull it out of the wall to get it to work. Findings include: R16 was admitted to the facility on [DATE] with diagnosis that included Hemiplegia and Chronic Respiratory Failure. R16's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and documented R16 had a Brief Interview for Mental Status score of 14 which would indicate he is cognitively intact and able to make his needs known. On 06/17/24 at 9:36 AM, Surveyor observed R16 lying in bed in his room. R16 indicated for the past 2 or 3 days his call light has not worked when pressed and to get it to ring he has to pull it out of the wall. R16 indicated he reported it to nursing and no one has fixed it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure there were enough linens in the facility. This has the potential to affect more than a limited number of residents on any given day. There was a shortage of towels, washcloths, and sheets available for staff to assist residents with cares. As a result of this deficient practice, bath blankets were cut up for resident use as towels, showers were delayed due to no towels, and washcloths were provided as towels for personal care. Findings include: Review of the facility's policy titled Bathing a Resident, implemented 03/01/19, revealed It is the practice of this facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. Equipment and supplies include: .washcloths and towels . Review of the grievance log provided by the facility revealed a grievance filed on 01/06/24 which documented Summary of Concern: NHA (Nursing Home Administrator) went to do an audit on how much linen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure a baseline care plan was in place and copy shared with the resident/resident representative within 48 hours of admission for 4 of 5 residents (R11, R13, R14, and R15) reviewed for baseline care plan. As a result of this deficient practice, newly admitted residents may not receive needed nursing care, or interventions as directed by physician orders and resident assessment. Findings include: Review of the facility's policy titled Baseline Care Plan, implemented 03/01/19, documented The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours [two days] of a resident's admission. A written summary of the baseline care plan shall be provided to the resident and representative in a language…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, and facility policy review, the facility failed to ensure there was consistent application of approved cleaning chemicals for the decontamination and daily cleaning of resident rooms for 2 of 4 resident hallways (Hallway B and C). As a result of this deficient practice, the failure had the potential to cause cross contamination of bacteria and potential to mix bleach with cleaning products causing hazardous fumes within the resident rooms. Findings include: During an observation on 05/29/24 at 11:08 AM on B Hallway HA H (Housekeeping Aide) was deep cleaning a resident room. The housekeeping cart had a spray bottle of diluted bleach and a spray bottle of diluted Fabuloso (odor removing spray). During an interview on 05/29/24 at 11:10 AM, HA H explained when deep cleaning a room to spray the diluted bleach solution on the floor then spray the Fabuloso on the floor because of the strong smell of the bleach. During an interview on 05/29/24 at 12:30 PM, HA I explained when cleaning flat surfaces in a resident's room, she used diluted Santastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, has a national certification for food service management and safety from a national certifying body, or who has an associate's or higher level degree in food service management or hospitality. This had the potential to affect all 105 residents residing in the facility. Findings include: On 10/9/23 at 1:47 PM, Surveyor interviewed Dietary Director (DD)-D who confirmed Registered Dietician (RD)-I is the facility's current RD. DD-D indicated RD-I is not in the facility and works fully remote. DD-D indicated DD-D is in the process of becoming a certified dietician, but has not completed the course. DD-D stated during weekly meetings, the facility discusses hiring updates for an in-house RD because it is easier when the RD works in the facility. On 10/10/23 at 12:34 PM, Surveyor interviewed DD-D who indicated DD-D has previous long-term care experience in housekeeping, laundry,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, and record review, the facility did not implement a pest control program that effectively addressed flies and gnats. This had the potential to affect all 105 Residents (R) residing in the facility. Houseflies and gnats were observed in resident rooms and throughout all four wings of the facility. Findings include: The Centers for Disease Control and Prevention (CDC) recommendation titled Guidelines for Environmental Infection Control in Health-Care Facilities updated July of 2019 states: From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. Modern approaches to institutional pest management usually focus on: a. eliminating food sources, indoor habitats, and other conditions that attract pests; b. excluding pests from the indoor environments; and c. applying pesticides as needed. A-Wing Hallway During an initial facility walk-through observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff and resident interview, the facility did not ensure a sanitary, comfortable, and home-like environment for 3 Residents (R) (R9, R7, and R10) of 16 sampled residents. Surveyor observed a large, brown, dried spill on R9's floor on 10/9/23 and 10/10/23. Surveyor also observed a leaking toilet in R9's room. Surveyor observed areas of dirt and grime on R7 and R10's floor as well as white-colored splatter on furniture in the room. In addition, R7's bed lacked front wheel supports and the commode in R7's bathroom contained rust. Findings include: The facility's position description for Housekeeper, last revised 11/2019, states in primary duties that the housekeeper should: Ensure that quality standards, safety guidelines and customer service expectations are met. The housekeeper is responsible for satisfactory and timely completion of assigned cleaning area according to schedule. Reports equipment/cleaning product needs and or malfunctions to supervisor in a timely fashion. Areas…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview, and record review, the facility did not thoroughly investigate and resolve grievances for 3 Residents (R) (R7, R9, and R6) of 14 sampled residents. The facility did not thoroughly investigate, determine root-cause, document details, and provide satisfactory resolution to a grievance filed by R7's family on 4/20/23. The facility did not thoroughly investigate and document a grievance filed by R9's family on 5/15/23. The facility did not thoroughly investigate, document, and provide resolution to a grievance filed by R6 on 6/1/23. Findings include: The facility's Grievance policy, implemented 3/1/19, indicates: Section B: The facility will train and designate an individual who is responsible for .Work with facility staff utilizing root cause analysis processes for resolution of the grievance or concern .Section H. Resolution, part (b) states: The Grievance Official will complete a written response to the resident or resident representative which includes: i.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility failed to to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act for 2 Residents (R) (R15 and R16) of 4 residents reviewed. A facility investigation, dated 5/25/23, determined Certified Nursing Assistant (CNA)-U engaged in verbal abuse of residents on 5/18/23. The incident was not reported to law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 10/01/22, indicated: Reporting: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe .a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that causes the allegation do not involve abuse and do not result in serious bodily injury. On 10/10/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment was as free of accident/hazards as possible for 3 Residents (R) (R1, R13, and R14) of 14 sampled residents. R1 obtained a second to third degree burn from coffee and did not have care plan and safety interventions implemented to prevent burns from hot liquids. R13 did not have care plan and safety interventions implemented to prevent burns from hot liquids. R14 did not have interventions in place to prevent an adverse outcome from ingesting cigarette butts. Findings include: 1. On 10/9/23, Surveyor reviewed R1's medical record. R1's Minimum Data Set (MDS) assessment, dated 8/4/23, contained a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R1's cognition was severely impaired. The MDS indicated R1 was assessed as independent for eating and didn't require help aside from set up assistance. R1's Hot Liquid Safety Assessments indicated the following: This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and record review, the facility did not ensure food was prepared in a form designed to meet the needs of residents with a mechanically altered diet for 1 Resident (R) (R4) of 1 sampled resident. R4 had a diet order for Dysphagia Level 3 Advanced (smaller than bite-sized pieces/chopped) diet texture. During the lunch meal on 10/9/23, R4 was served spaghetti with whole meatballs and noodles. During the lunch meal on 10/10/23, R4 was served an oatmeal raisin cookie. Findings include: The National Dysphagia Level 3 Advanced Nutrition Therapy documented titled Dysphagia Level 3 Advanced Diet food recommendations and foods to avoid document located at https://nebula.wsimg.com written by the American Dietetic Association indicated: Dysphagia Level 3 Advanced Diet consists of food of nearly regular textures with the exception of very hard, sticky, or crunchy foods. Foods still need to be moist and should be in bite-size pieces at the oral phase of the swallow .recommended meats .thin-sliced, tender, or ground meats and poultry .avoid .dry cakes, cookies…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, the facility did not ensure food preferences were honored for 1 Resident (R) (R4) of 1 sampled resident. R4's meal card listed R4's food dislikes which included spaghetti and tacos. During observations on 10/9/23 and 10/10/23, R4 was served spaghetti and taco meat. Findings include: On 10/9/23, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE]. R4's Minimum Data Set (MDS) assessment, dated 8/31/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R4 had intact cognition. R4's care plan indicated R4 was at risk for malnutrition/dehydration or other nutritional problem due to a history of pain, CHF (congestive heart failure), hypokalemia, HTN (hypertension), chronic a-fib, edentulous (without any natural teeth), underweight BMI (body mass index) for age, and had a liberalized diet to promote by mouth (PO) intake. An intervention instructed staff to honor and update food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility did not ensure residents right to a safe, clean, comfortable and homelike environment for 3 of 4 units observed with the potential to affect R10, R43, R27, and those residents residing on unit D * R10's window curtain was dirty and contained numerous incontinence brief tabs. * R43's bedroom floor was dirty, and there were paint chips and crumbling drywall observed. * R27's wall behind R27's bed was observed to have scattered chips of paint and dry wall gouged out along with a hole on wall where the dry wall is crumbling * Unit D hallway was observed to have paint chips, markings and and holes in walls. This deficient practice has the potential Findings include: The facility Policy and Procedure titled Daily Cleaning Procedures which is not dated, documents (in part) . . 5) Disinfect: Work your way clockwise around the room (starting at the door and finishing at the door) and dust all high surfaces. This includes, but is not limited to: Pictures/prints,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 6 of 7 Residents (R) (R4, R63, R74, R64, R31 & 2) reviewed for hospitalizations and their responsible parties, received a transfer notice to include date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman in writing. Additionally, the facility did not notify the State Long-Term Care Ombudsman of transfers and discharges. *R4 was transferred/discharged to the hospital on [DATE] and there is no indication the Guardian for R4 and the State Long-Term Care Ombudsman were notified of the transfer. *R63 was transferred to the hospital on 1/9/23 and 1/18/23. The State Long-Term Care Ombudsman was not notified of the transfer/discharge from the facility. *R74 discharged to the hospital on 1/6/23. The State Long-Term Care Ombudsman was not notified of the discharge from the facility. *R64 tranferred to the hospital four times and the State Long-Term Care Ombudsman was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not provide a bed hold notice upon transfer to the hospital as required for 6 of 7 Residents (R) (R4, R63, R74, R64, R31 & R2) reviewed for hospitalization. *R4 discharged to the hospital on [DATE]. A bed hold notice was not provided to R4 and R4's representative at the time of transfer. *R63 discharged to the hospital on 1/9/23 and 1/18/23. A bed hold notice was not provided to R63 and R63's representative at the time of transfer. *R74 discharged to the hospital on 1/6/23. A bed hold notice was not provided to R74 and R74's representative at the time of transfer. *R64 discharged to the hospital four times. A bed hold notice was not provided to R64 and to R64's representative at the time of transfer. *R31 discharged to the hospital on [DATE], 12/14/22, 12/28/22, and 2/9/23. A bed hold notice was not provided to R31 and R31's representative at the time of transfer. *R2 discharged to the hospital on [DATE] and 2/15/23. A bed hold notice was not provided to R2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview the facility did not prepare food according to professional standards to maintain nutrition. [NAME] H was observed preparing pureed foods without using a recipe. This deficit practice has the potential to affect 5 of 5 residents recieving pureed foods. Fidnings include: On 03/14/2023, at 8:28 AM, Surveyor observed [NAME] H prepare puree food. [NAME] H began scooping cooked, chopped chicken into the food processor with a one cup scoop. [NAME] H put 6 and ½ cup scoops of chicken into the food processor. [NAME] H informed Surveyor she usually adds a little bit of broth at a time until the puree comes to the right consistency. Surveyor asked [NAME] H if she follows a recipe. [NAME] H stated no, I just add the broth to consistency. [NAME] H then placed 3 ounces of thickener into the food processor. [NAME] H then grabbed an eight-cup container of chicken broth. The broth came to just under the seven-cup line on the container. [NAME] H started the machine, added a little bit of broth, continued processing and then added the remainder of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 kitchen. * Staff were not monitoring the accuracy of the temperatures on the high temperature dishwashing machine. * Staff member was observed touching ready to eat food items with a gloved hand, changing tasks wearing the same gloves, and then continuing to touch ready to eat food items without changing gloves or performing hand hygiene. * Food storage: Items stored in the freezer were observed closer than 6 inches from the floor. The reach in refrigerator had out dated food items. Items in the dry storage were observed to be close to the foil lined vent duck that was lower than the ceiling. Surveyor noted there were five boxes stored on the top shelf of this shelving unit and one of the boxes was touching the foil-lined vent duck. The other boxes appeared close to the vent, but not touching the vent. These deficit practices have the potential to affect all 100 residents who receive food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did in ensure that an individualized plan of care was developed for 1 (R74) of 20 residents reviewed. *R74 is a diabetic and receives insulin. The facility did not develop an individualized plan of care to address that R74 is a diabetic and receives insulin. R74's plan of care also did not include that R74 often refuses insulin and includes specific interventions to assist R74 is being compliant with physician's orders. Findings Include: The facility's policy and procedure, titled, Comprehensive Care Plans, dated 10/01/22, documents: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .Resident specific interventions that reflect that resident's needs and preferences and align…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, 1 Resident (R73) of 1 dependent residents reviewed did not receive required assistance with Activities of Daily Living. * R73 did not receive assistance with toileting in accordance with facility protocol. Findings include: R73 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, weakness and cognitive communication deficit. R73's Annual MDS (Minimum Data Set) assessment dated [DATE] indicates that R73 requires extensive assistance of 1 staff with toileting. R73 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R73 is cognitively intact. On 3/14/23 at 1:26 PM, Surveyor made observations of R73. R73 was observed in their bedroom in a high back wheelchair with 2 large puddles on the floor beneath their chair. R73 told Surveyor they think they made a big mess and needed help from staff. Surveyor asked R73 when the last time they were last assisted with toileting. R73 told Surveyor they hadn't been changed since they got…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 (R301) residents reviewed for an RN assessment after having a fall and for 2 of 3 (R10 and R507) residents reviewed for skin integrity. * R301 fell on [DATE]. R301 reported she fell and the CNA put her back to bed. R301 reported her leg was broken. The CNA did not get an RN to conduct an assessment of R301 prior to placing R301 back into bed. There was no evidence of an RN assessment after R301 reported her leg broken, except for the ordering an X-ray, which confirmed the fracture. * R10 was admitted on [DATE] with current skin issues. R10's skin issues were were not comprehensively assessed or measured until R10 was seen by the would physician on 2/6/23. Treatment for the wounds was not implemented until R10 was seen by the wound physician on 2/6/23. A facility weekly skin assessment was not completed until 2/13/23. Additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 3 of 6 (R163, R11, R253) residents reviewed for nutrition and weight loss. * R163 was not weighed weekly according to the facility's policy. In additon, R163 had a documented weight loss of 5.2% in 1 month with no interventions. * R11 had oral surgery on 11/2/22 and having all her teeth extracted in preparation for dentures. Surveyor could not locate any Dietary progress notes after 11/2/22 when R11 had her teeth extracted to assess for pain and chewing. On 12/9/22 a significant weight loss was identified with a weight loss of 9% in 1 month with not interventions. No documentation of a reweigh was conducted to confirm the weight loss and no weight was documented until 1/10/23. No new interventions or updates to the care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility did not ensure 1 (R74) of 1 residents reviewed, received appropriate respiratory care, including monitoring for signs and symptoms of COVID-19 infection. *R74 tested positive for COVID-19 on 3/11/2023. The facility was not monitoring R74 for signs and symptoms daily to ensure R74 did not develop symptoms or that R74's symptoms were improving. Findings Include: Surveyor requested a policy and procedure on monitoring a resident who is positive for COVID-19. Surveyor was provided with a copy of the facility policy Novel Coronavirus Prevention and Response, however, this policy did not address monitoring residents' symptoms who are positive for COVID-19. R74 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Anxiety Disorder, and Pneumonia. R74's Quarterly MDS (Minimum Data Set) assessment dated , 1/19/23, documents a BIMS (Brief Interview for Mental Status) score of 10, indicating R74 is moderately cognitively impaired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 1 (R63) of 1 residents who receive dialysis had the necessary assessment and care plan. * R63 receives dialysis and there are no assessments of R63's dialysis access site and R63's care plan does not address the care and treatment of R63's dialysis access site. Findings include: The facility policy and procedure, titled, Dialysis, dated 06/2021, documents: General: To provide guidance to the facility on how to care for the dialysis resident . .4. The Dialysis site will be checked and monitored for abnormalities daily and/or as needed . Surveyor was unable to observe R63's dialysis access site due to R63 being in dialysis and out of the facility. R63 was admitted to the facility on [DATE] with diagnoses of encephalopathy, Type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis. R63's physician progress note, dated 1/26/2023, documents R63 has a fistula and attends dialysis three times per week. Surveyor reviewed R63's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not ensure the accurate monitoring for expiration dates of all drugs and biological's to meet the needs of each resident for 1 of 1 (R69) residents reviewed. Findings include: The facility policy and procedure titled Medication Administration General Guidelines did not include information specific to verifying the expiration date of medications. On [DATE] at 9:00 AM Surveyor observed the facility medication room between units B and C. The refrigerator contained an opened bottle of Pantoprazole 2 mg (milligrams)/ml (milliliters) liquid belonging to R69. The label on the bottle read discard after [DATE]. On [DATE] at 9:10 AM Surveyor showed Medication Technician (MT)-U the expiration date on the bottle of Pantoprazole belonging to R69. MT-U reported she would discard the medication. On [DATE] at 3:15 PM during the daily exit meeting Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were advised of the expired bottle of Pantoprazole belonging to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not have an attending physician review and document on an identified medication irregularity for 1 (R2) of 5 residents identified in a pharmacy medication regime report. * The facility did not have documentation the physician addressed R2's Pharmacy Recommendation from October 2022. Findings include: R2 was admitted to the facility on [DATE] with diagnoses including presence of prosthetic heart valve, atrial fibrillation, schizophrenia, anxiety, depression, malignant neoplasm of prostate and chronic kidney disease stage four. R2's admission MDS (Minimum Data Set) Assessment with an Assessment Reference Date of 12/22/22 documented, R2 had a BIMS (Brief Interview for Mental Status) of 15, indicating R2 is cognitively intact and documented R2 used anticoagulation medication 7 out of the last 7 days. R2's care plan, initiated 10/09/2022, documented, At risk for complications related to anticoagulant or antiplatelet medication due to: Warfarin, ASA (Aspirin) and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not keep 1 (R2) of 5 residents reviewed free from unnecessary drugs. * R2 received Lovenox and Warfarin/Coumadin (anticoagulant) without adequate monitoring by ensuring PT/INR (prothrombin time test and international normalized ration) labs were conducted. R2's INR lab stopped after 12/26/22 until 1/16/23. On 1/16/23 R2's INR was 1.3 subtherapeutic. On 2/15/23 R2 was admitted to the hospital and readmitted on [DATE]. The hospital discharge summary indicated to do an INR on 2/27/23. There was no INR completed from 2/27/23 until 3/7/23. An INR result on 3/7/23 was 1.1 subtherapeutic. The Nurse Practitioner(NP) reported INRs should have been checked 2 times a week and with INRs to be between 2.5 and 3.5. There were no INR lab results between 3/13 and 3/19/23. On 3/20/23 R2 was sent to the hospital due to a fall and returned to the facility on the same date. On 3/20/23, the on call nurse practitioner was made aware of a critical lab INR of 7.1 with orders to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not implement individualized behavior monitoring for 2 (R2, R163) of 5 residents receiving psychotropic medications. *R2's behaviors were not monitored in accordance with standards of practice while receiving psychoactive medications. *R163's behaviors were not monitored in accordance with standards of practice while receiving psychoactive medications. Findings include: 1. R163 admitted to the facility on [DATE] and had diagnoses that include right femur fracture, right humerus fracture, alcoholic cirrhosis of liver, alcohol induced chronic pancreatitis, Bipolar Disorder and anxiety disorder. R163's History and Physical (H&P) documented medications upon admission included Seroquel 200 MG (milligrams) daily for anxiety. The H&P documented history of alcohol abuse, Bipolar disorder, depression, cocaine use disorder, history of sexual abuse in childhood at age [AGE], history of suicide attempt . R163's admission Minimum Data Set (MDS) dated [DATE] section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews and record review the facility did not ensure its medication error rates was not 5 percent or greater. There were 2 errors in 30 opportunities for R38 which resulted in an error rate of 6.67%. * On 3/15/23 at 7:39 AM Surveyor observed Licensed Practical Nurse (LPN)-AA prepare R38's medications. LPN-AA crushed the enteric coated Aspirin. LPN-AA also prepared 2 tablets of Cyanocobalamin Oral Tablet 500 mcg instead of 2 tablets of 1000 mcg as ordered. Findings include: The facility policy titled Medication Administration General Guidelines dated 12/17 documents (in part) . . 4) Five rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration. 7) Tablet crushing/capsule opening: Crushing tablets may require a physician's order, per facility policy. If it is safe to do so, medication tablets may be crushed or capsules empties out when a resident has difficulty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility did not ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 1 of 2 medication rooms observed with the potential to affect R75. * 2 Insulin pens were observed to have been opened and used, but not dated when opened, one of which did not contain a label with a resident's name. Findings include: The facility did not have a policy and procedure specific to dating of insulin, but provided a form from pharmacy titled Expiration of Insulin Vials (not dated) which documented (in part) . .Humalog (lispro) rapid acting. Unopened - until expiration date. Open - 28 days. On 3/20/23 at 9:00 AM Surveyor observed the medication room between units B and C. The refrigerator contained two 100 ml (milliliter) Humalog insulin Kwik pens one of which was not labeled with a resident's name, the other was labeled with R75's name. Surveyor noted both insulin pens were open and used, but not dated when opened. On 3/20/23 at 9:10 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility did not ensure each resident received food and drink that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 (R157) residents reviewed. R157 breakfast tray consisting of fried eggs and sausage was observed on the tray table in his room for approximately 3.5 hours while he was at dialysis. R157 consumed the food upon return from dialysis. Findings include: The facility Policy and Procedure titled Food Temperatures which is not dated, documents (in part) . . Foods will be maintained at proper temperature to insure food safety. 6. The following range of temperatures is recommended for food at point of tray assembly: b. Meat, portioned for service 160 degrees F 7. Heating food in the steam table is prohibited. Heating food to the proper temperature is accomplished by direct heat (stove, oven, steamer, etc.) and food is then transferred to the steam table not more than 30 minutes before meal service. The facility Policy and Procedure did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.